acute ling injury ards

Card Set Information

Author:
jam110007
ID:
286447
Filename:
acute ling injury ards
Updated:
2014-10-20 21:08:52
Tags:
medsurg resp
Folders:
medsurg resp exam 3
Description:
medsurg exam 3
Show Answers:

Home > Flashcards > Print Preview

The flashcards below were created by user jam110007 on FreezingBlue Flashcards. What would you like to do?


  1. Acute lung injury
    Acute lung inflammation with diffuse alveolar-capillary injury => right to left shunting => severe hypoxemia requiring mechanical ventilation.
  2. normal PaO2 : FiO2 ratio
    100 mg Hg / 0.21  = 476
  3. acute lung injury and ARDS PaO2:FiO2
    • acute lung injury
    • - < 300
    • ARDS
    • - < 200
  4. Etiology: Direct
    • - * Aspiration of gastric content => Pneumonitis
    • - Burns – direct inhalation of gases
    • - Cardiopulmonary Bypass
    • - Near Drowning
    • - Inhalation of toxins
  5. Etiology: indirect
    • - Systemic burns
    • - DIC
    • - Multiple fractures
    • - *Trauma
    • - Pancreatitis
    • - Prolonged Hypotension
    • - **Sepsis – number one reason
  6. Clinical Manifestations
    • - Dyspnea
    • - Tachypnea, shallow
    • - Dry cough
    • - Retrosternal discomfort
    • - Agitation
    • - ↑  WOB
    • - Cyanosis
    • - Coarse Crackles
    • - Bronchial breath sounds – what are the normal breath sounds over peripheral lung tissue?
    • - Refractory hypoxemia
  7. Progression Of ARDS
    - Hyperventilation => Respiratory Alkalosis=> Dyspnea & Hypoxemia => Metabolic Acidosis => Hypoventilation (Pt fatigued from => WOB) => Respiratory Acidosis => Further Hypoxemia => Hypotension, => CO, Death
  8. three phases of acute lung injury
    • - injury 
    • - reparative/prliferative 
    • - fibrotic
  9. Pharmacological Agents
    • Bronchodilators
    • - Beta 2 Adrenergic Agonist (Alupent, Albuterol via nebulizer on the vent)

    • Anticholinergics
    • - Atrovent via nebulizer
    • - Combivent – Albuterol mixed w/ Atrovent

    • Corticosteroids
    • - Solucortef IV, Solumedrol IV(less Na+ retention)

    • Antibiotics
    • - broad spectrum and then based on culture reports

    • Anticoagulants
    • - SC Heparin, LMWH

    • Gastric protection
    • - Proton Pump Inhibitors, H2 Antagonists
  10. Criteria for Ventilatory Support
    acute ventilatory failure 

    acute hypoxemia 

    • pulmonary mechanics
    • - resp rate
    • - vital capacity (max air expired after max inspiration nl 65-75ml/kg)
  11. Critical Values Ventilatory Support
    • - PaCO2 > 50 mm Hg
    • - pH < 7.30 (not COPD – chronic issue)
    • - PaO2 < 60 mm Hg
    • - Rate > 35 - increase WOB
    • - VC < 15 mL/Kg (Restrictive disease decrease lung compliance)
  12. Mechanical Ventilation
    • Endotracheal Intubation
    • - Anesthesia Tray with laryngoscope , ET tubes, AMBU Bag, oxygen source (12-15 LPM), CO2 monitor, Stethoscope

    •                  Meds:
    • Induction Agent
    • - Etomidate 0.03 mg/kg
    • - Propofol 2 – 2.5 mg/kg

    • Paralytic Agent
    • - Succinylcholine 1 – 1.5 mg/kg
    • - Vecuronium 0.08 – 0.1 mg/kg
  13. types of Ventilators
    • - CMV – Controlled Mechanical Ventilation
    • - Volume Control
    • - Pressure Control
    • - Synchronized Intermittent Mandatory Ventilation (SIMV)
    • - CPAP, BiPAP, PEEP
  14. Controlled Mechanical Ventilation
    • - Ventilator in complete control (rarely used)
    • - Delivers set Tidal Volume at a set rate
    • - MV = 500 mL x 12 BPM = 6.0 L/min
    • - May be used in patient is completely paralyzed by meds & no chance of inspiratory effort

    • - Tidal Volume 500 mL
    • - Resp Rate 12/BPM
    • - FiO2 40 %
    • - PEEP 5 cm H20
  15. Volume Control ventilator
    • - Ventilator Controls Volume
    • - If patient takes a breath it will deliver a set tidal volume
    • - Any breaths the patient takes above set rate will also receive a set volume

    Advantage – deliver a set minimum MV

    • Disadvantage - If lung gets stiff  decrease compliance => lung damage
    • - Pneumothorax
    • - Barotrauma
  16. Pressure Control ventilator
    • - Ventilator will control pressure delivered and volume will vary
    • - Peak pressure: 24 cm H2O
    • - Resp Rate: 12 BPM
    • - FiO2: 40 %
    • - PEEP: 5 cm H2O

    • Advantage
    • - Avoid trauma to lung tissue

    • Disadvantage
    • - Lung compliance changes with positioning, suctioning, disease process
    • - Need to monitor patient carefully maybe under-ventilated or over ventilated
  17. Synchronized Intermittent  Mandatory Ventilation (SIMV)
    • - Most common mode
    • - Patient taking control of breathing – patient weaning from ventilator support
    • - Patient’s spontaneous breath is supported by the ventilator
    • - No support with machine delivered breaths

    • - Tidal Volume 500 mL
    • - Resp Rate 12/BPM
    • - Fi O2 40 %PEEP 5 cm H20
    • - Pressure Support 10cm H2O
  18. Positive End Expiratory Pressure (PEEP)
    • - INVASIVE via ET & Mechanical Ventilation
    • - At the end of expiration there is a positive pressure that remains in the airway to keep alveolar sacs open.
    • - Improves aeration/ventilation exchange
    • - Recruits more alveolar sacs for ventilation that normally would collapse due to disease process
    • - Consequence: May decrease CO due to increase Intrathoracic pressure – need to monitor hemodynamic effects
  19. Continuous Positive Airway Pressure CPAP
    • - Non-invasive via mask or nasal prongs
    • - like PEEP but patient is responsible for breathing on own
    • - Sleep Apnea
    • - A constant pressure remains during inhalation/exhalation
    • - Need increased effort to exhale – no longer passive
    • - Some patients feel like they are suffocating – fight the machine
  20. Bi-Level Positive Airway Pressure BI PAP
    • - Higher level of pressure is set for inhalation to augment patient’s spontaneous breathing
    • - Lower level of pressure is set during exhalation so the patient can exhale against a lesser flow

    - IPAP – Inspiratory Positive Airway PressureEg. 10 cm H2OE

    - PAP – Expiratory Positive Airway PressureEg. 5 cm H2O
  21. Pharmacology w/ Mechanical Ventilation: sedation/pain
    • Anxiety
    • - Lorazepam(Ativan) Drip1-4 mg/hr
    • - Midzolam(Versed) Drip1-15 mg/hr
    • - Propofol(Diprivan) Drip0.5-10 mg/kg/hr

    • Pain
    • - Morphine Drip2-20 mg/hr
    • - Fentanyl Drip50-300 ug/hr
  22. Pharmacology w/ Mechanical Ventilation:Neuromuscular Blockade
    • - Pancuronium(Pavulon) Drip 0.1mg/kg/hr
    • - Vecuronium )Norcuron 0.05  1.0mg/kg/hr

    - Train of Four Assessment :Application of four successive electrical stimuli to the ulnar nerve. Count the twitches. Need ¼ or 2/4
  23. ventilator: nutrition
    • - Small frequent feedings
    • - Mechanical soft – easily prepared, easily chewed
    • - Limit Liquids at meals
    • - Plan meals for after rest
    • - Hi Calorie, High protein, high fat, Low carbCHO increase CO2 production
  24. ventilator goals
    • Promote Adequate Oxygenation
    • - Reverse hypoxemia PaO2 > 60 mm Hg
    • - Reverse Hypercarbia
    • - Maximize O2 carrying capacity - check Hgb

    Decrease O2 consumption –minimize fever, activity level, respiratory effort, anxiety

    Prevent Infection

    Prevent MODS
  25. ventilator interventions
    • Through Respiratory Assessment
    • - VS esp Resp rate, WOB, O2 sat, lung sounds, check Cyanosis, Monitor ABG’s, PaO2:FiO2 ratio, LOC, pain/anxiety, Energy Conservation

    • Positioning
    • - High Fowlers Research (Badr, 2002) Healthy subjects & COPD pts increased their maximal expiratory pressure by sitting up lean forward with head down

    - Prone Position on vent – Research: (20% increase PaO2, ↑PaO2:FiO2 ratio within 2 hoursno effect on mortality

    - Continuous Lateral RotationResearch: ( Wang, 2003; Kirshenbaum, 2002) - ↓ incidence of VAP and increased oxygenation
  26. Ventilator Acquired Pneumonia
    • - Aspiration of oro-pharyngeal organisms
    • - High rate of Gram Neg bacilli in oro-pharygeal & tracheobronchial tree
    • - Colonization on the dorsal tongue
    • - Contaminated nebulizers used for airway humidification
    • - Endotracheal suction techniques
  27. Evidence-based Practice  to Prevent VAP “VAP Bundle”
    • Reduce the duration of ventilation
    • - Monitor patient for spontaneous breathing
    • - Reduce use of sedatives

    Avoid unplanned extubation which requires intubation – natural instinct to pull the tube out

    Intermittant & continuous suction of subglottic secretions – prior to position changes

    HOB 30-45 degrees

    • Oral hygiene
    • - Not just a comfort measure
    • - Reduces colonization
    • - Brush teeth, tongue, gums 2x/day
    • - ----Soft toothbrush & yankauer suction
    • - Oral decontamination w/Chlorhexidine
  28. Emotional support
    • - Research: Gift, (1992) 26 COPD patients were taught relaxation techniques which ↓ dyspnea and anxiety but it was not sustained after sessions
    • - Research: (Lewith, 2004; Maa, 2003) COPD patients ↓ dyspnea with acupuncture and/or acupressure
    • - Research: Louie, 2004; Moody, 1993) Guided imagery was not effective in ↓ dyspnea in COPD patients
  29. Cor Pulmonale
    • - RV Failure R/T pulmonary restrictive, obstructive or vascular disorder
    • - decrease PaO2 & increase PaCO2 => Acidosis => Pulmonary Vascular Resistance => Pulmonary HTN => Right Ventricular Hypertrophy => CHF

What would you like to do?

Home > Flashcards > Print Preview